Functional decline and disability are common consequences of hospitalization in older adults. Over the last decade, increasing numbers of older adults received post-acute rehabilitative services at skilled nursing facilities (SNFs) and the dominant admission diagnoses have shifted from acute disabling conditions such as stroke and hip fracture to general medical conditions such as pneumonia and heart failure. While medical acuity seems to be increasing in SNFs, the organization and content of medical care remains underdeveloped, and medical care is not explicitly coordinated with rehabilitative care. Although recovery from hospitalization- associated disability is critical for maintaining health and function, relatively little is known about the determinants and outcomes of SNF-based post-acute care (PAC), especially for general medical conditions. The proposed project will lay a foundation for research to improve medical care and to increase coordination of medical and rehabilitative care in the SNF setting. To better understand who uses SNF care and what happens to them, this project will identify the characteristics that determine the use of post-acute care (PAC) among older adults, compare outcomes across post-acute settings, and identify factors associated with the functional outcomes of SNF-based PAC. This study will use the 1996-2003 Medicare Current Beneficiary Survey (MCBS), a nationally-representative in-person panel survey of Medicare beneficiaries linked with claims data. The specific aims are 1) to identify the demographic, medical, and health status factors that predict the use of PAC among hospitalized community-dwelling older persons and, among users, the type of PAC (SNF-based versus a home health agency (HHA) or rehabilitation hospital);2) to compare outcomes of PAC in SNF versus HHA or rehabilitation hospital, after adjusting for primary diagnosis, comorbidity, prior functional status, and health care utilization;and 3) to determine the effect of intensity of PAC on outcomes among SNF patients, after adjustment for comorbidity, prior functional status, principal rehabilitation diagnosis, and health care utilization. The MCBS is uniquely suited to these aims because it contains information for community-dwelling and institutionalized participants about PAC use, discharge diagnoses, self-report health status and functional information from both before and after an episode of PAC use. Information about SNF-based PAC as it has evolved in recent years will establish a foundation for more clinically detailed prospective studies of PAC outcomes, specifically studies to develop an index of medical issues that influence functional recovery. This future index, like an APACHE score, could support prognostic and ultimately treatment guidelines for care of medically complex, recently disabled older adults. The preliminary information obtained from this nationally representative sample will allow us to define representative samples, estimate outcome rates and specify influential patient factors as we proceed. PUBLIC HEALTH RELEVANCE: Over the last decade, more and more older adults are discharged from the hospital too sick and weak to go home, and so spend time in the rehabilitation program at a skilled nursing facility. This study will determine who is using nursing facilities after hospitalization, the kinds of medical and functional problems they face, and will help determine the individual and health system factors that are associated with functional recovery. The long term goal of this research is to improve medical and rehabilitative care in the skilled nursing facility in order to provide older adults with the best opportunity for functional recovery and return to home.